OncologyLive® is the flagship publication of OncLive®. Each issue delivers expert insights and clinical oncology news and updates, which impact the day-to-day clinical practice of oncology professionals who work tirelessly to help improve patient outcomes.

Cancer care is rapidly evolving. Over the last decade we have seen the advent of new chemotherapy drugs and novel classes of agents such as targeted therapies that aff ect signal transduction pathways; angiogenesis inhibitors and vaccines are becoming routine components of care; radiation therapy technologies continue to improve with the arrival of IGRT and other modalities; and minimally invasive surgical techniques are making rapid progress.

Unfortunately, these advances in the science of oncology have been accompanied by a variety of challenges to the fi nancial health of many oncology practices. As reimbursements have steadily declined and tighter restrictions have been placed on the use of many of these novel tools, some smaller practices have been pushed to the brink of insolvency. Th is is in part because oncology practice is increasingly marked by a curious dichotomy, wherein physicians are receptive of the latest advances in clinical science and technology, but resistant to (or unaware of) new developments in information technology that are just as essential to their practices.  Commentators in the media have often provided one-sided, inadequate explanations for the causes of this, in many cases lacking the experience and depth of knowledge necessary to truly understand the challenges faced by oncology practices.  What many observers (and oncology professionals, as well) fail to understand is that as the treatments we provide for our patients have grown in complexity, so too have the business processes and tools that must be employed to ensure the continued health of our practices. In order to operate efficiently, practices must improve productivity, doing more with fewer people while maintaining or enhancing the services provided to patients.

Oncologists must also come to grips with the fact that healthcare is becoming increasingly service-oriented and consumer-centric.  As new decision-support tools emerge in oncology, we will also see more algorithm-driven care with embedded predictive modeling. Some of these tools will be incorporated into EMR systems, adding to the challenges of product selection and implementation many practices are currently facing. Th ese new technologies will not only support the patient journey but also capture information as a byproduct of workfl ow. Mining this information will allow us to optimize operational effi ciencies and clinical outcomes in the pay-for-performance environment required by payers and the changing expectations of oncology patients and their families. Newer patient tools, such as gene expression assays, will not only make risk assessment and cancer care more personalized, but also aff ect how patients utilize our services, requiring us to adjust our business practices. Clearly, the clinical, IT, and business domains will be integrated more tightly than ever before.

The pursuit of next-generation cancer care will always be the correct path. The challenge is to define what that means for oncology professionals and their patients, identify the tools we need to produce the desired outcomes, and find pragmatic ways to pursue our goals. Due to several attractive tax incentives for hardware and software purchases, this year is a particularly important year for making IT investment decisions. How are you building your strategic vision? How will you defi ne the path forward and the priorities that you will pursue? How will you pay for it?  Over the next few months, this column will focus on new health IT tools and processes and the ways in which they can benefi t oncology care and the fi nancial health of your practice. I will cover decision-support tools, economic optimization through operational effi ciencies, breast cancer IT systems, utilization of improved clinical pathways, support for the patient cancer care journey, and other topics, reviewing key technology options and providing examples of successful best practices. I welcome your feedback and suggestions, and I look forward to engaging in a discussion about the challenges facing our profession as we move to make next-generation cancer care a reality.

Jivesh Sharma, MD, is CEO of Texas Cancer Associates, a midsize oncology practice based in Dallas/Fort Worth, TX. He is also CEO of HealthIT, an Internet services company that supports the patient/ provider network with technology solutions, and founder of NextGen Oncology, which works to provide next-generation solutions for the diagnosis, management, and treatment of cancer. E-mail Dr. Sharma at 

Articles

Oncologists must come to grips with the fact that healthcare is becoming increasingly service-oriented and consumer-centric.  

Oncology Outlook: Next-generation Cancer Care

Simon Cherry, professor and chair of biomedical engineering at UC Davis, discusses the combination of PET and MRI in a single scanner, which his lab built for laboratory mice studies, particularly in cancer research.

Until now, what has kept MRI and PET scans from being combined?

The two modalities have a big potential to interfere with each other. On the PET side, you worry about the very strong magnetic field environment from the MRI, and on the MRI side, you worry about the eff ect the materials in the PET scan will have on the uniformity of the magnetic fi eld and also the possibility that the PET anatomics will generate radiation that will perturb the MRI image.

PET and MRI studies in the same subjects have been done for many years, but the subjects have been moved from one scanner to the other. It’s very common to use both modalities, just not at the same time.

In traditional PET scanners, the detectors are based on photomultiplier tubes, which are extremely sensitive to magnetic fields. We moved to what’s called an avalanche photodiode (APD), a silicon sensor that’s very thin. Because the active region is so thin, it’s much more immune to magnetic fi elds. We’ve tested these devices in magnetic fi elds up to 9.4 tesla, and they work just fine.

On the MRI side, a number of things are important. First, arranging the components of the PET scanner symmetrically in the MRI scanner helps to prevent preservation of the magnetic fi eld. We also carefully shielded the electronics of the PET scanner to try to prevent radiofrequency interference. And we used materials wherever possible that have reasonable magnetic susceptibility, so that they are similar to human tissues. It’s all careful engineering to help protect artifacts on the MRI side.

What benefits will the combination provide to oncologists and their patients?

That’s the $1 million question for which we do not yet know the answer. We now have data that clearly show that this is feasible, and the question now is “are there applications out there that absolutely require PET and MRI data to be taken at the same time?” The things that spring immediately to mind are areas of the body in which MRI is a superior imaging technology to CT—the brain is an obvious case, as are the abdomen and pelvic areas. Particularly for oncology, you worry if you take the images a few hours apart in different scanners that things move around, and if you put the patient on two different beds, the organ positions are somewhat different.

It’s very hard to use computer software to register those two data sets. So, the ability to take the PET and MRI at the same time and know exactly where the PET’s localized with respect to the anatomy you get from the MRI, those applications are key. Just like PET/CT has had a huge role in oncology, I think PET/MRI will be the same. I think there is going to be a period of using this in the research arena to really understand what unique things can be done. For it to be a common, mainstream diagnostic tool, many other factors come into play, economics of course being one of them.

That’s harder to predict: will there be an application for which it makes a significant diagnostic difference and for which you can justify the cost (this is not going to be cheap)?

If you take this whole emerging field of molecular imaging, in which we’re really trying to image for example, specific sets of enzymes, they’re developing targeted agents to do this. As a tool that lets you really understand what you’re looking at and where the signal is coming from, the PET/MRI combo will be a really great device. For validating new biomarkers—many people are interested in using MRI as a biomarker for therapeutic effect&mdash;and to validate that specific radio tracing with PET in a pre-clinical situation and then clinical trials will be very helpful. I see a lot of applications in the research and drug development area. But my concern at a diagnostic level, as I mentioned, is where are the applications that justify the cost in a healthcare economy where, of course, costs are being tightly controlled for good reason. That’s going to be the challenge, but everyone said the same thing about PET/ CT 10 years ago; they weren’t quite sure what it was going to be used for. There were doubts about it being costeff ective. Now it is a mainstream modality, and nobody buys a PET scanner without a CT attached anymore. Maybe it will be the same with PET/MRI.

We’re trying now to develop a much-higher performance, second-generation system, and we’re also investing a lot of effort in trying to develop new imaging probes that are both MRI- and PET-visible at the same time.

Medical Devices: PET/MRI Combo

Mediastinal nodal involvement is an important factor in non—small cell lung cancer (NSCLC) staging to determine surgical resectability. Failure to identify mediastinal disease adequately may contribute to relapse, despite an apparently successful resection. However, the sensitivity and specificity of CT and PET in predicting malignant mediastinal nodal involvement are low. Accurate sampling with pathologic examination of intrathoracic nodes is the best predictor to determine prognosis and treatment

Cervical mediastinoscopy has the limitation of only accessing the left and right paratracheal, precarinal, and anterior subcarinal nodes, leaving aortopulmonary window and preaortic and subaortic nodes to be explored by an anterior mediastinotomy

or the posterior and inferior nodes by thoracoscopy. Pulmonologists can obtain cytological and even histological specimens with a bronchoscopic trans-bronchial needle aspiration (TBNA). After reviewing the nodal locations on CT or PET imaging, a bronchoscope is positioned in the appropriate site, and a needle is then inserted through the tracheal or bronchial wall to sample nodes.  Compared to mediastinoscopy, this is a blind technique, often resulting in a missed diagnosis.

Lately, ultrasound has been used to increase sampling accuracy. Trans-thoracic ultrasound does not provide adequate guidance because of the difficulty in imaging the mediastinum. A small ultrasound probe inserted in the airways, known as endobronchial ultrasound (EBUS), has been developed to localize nodes around the airways. At present, two types of EBUS are available: a radial probe and a linear probe. The radial probe is usually inserted through the bronchoscope for localization of nodes and is removed prior to the TBNA. So, the actual biopsy is not done under direct visualization. The advent of a dedicated bronchoscope with a linear probe attached to the tip allows nodes to be sampled under direct guidance. The bronchoscopic and ultrasound images can be monitored simultaneously, making it easier to locate the nodes. The nearby vascular structures are also identified with the color flow Doppler, minimizing any potential bleeding complications. EBUS—TBNA may be achieved with a 22G needle aspiration under direct ultrasound guidance in real-time from paratracheal, parabronchialand, or hilar lymph nodes with increased accuracy.  EBUS–TBNA has an overall sensitivity of 90% and a false negative rate of 24%.2 Recent data suggests that EBUS–TBNA sampling is defi nitive in 75% of patients with benign disease.

It has 89% sensitivity of detecting occult malignancy in clinical stage1 lung cancer with <1cm diameter nodes, suggesting that potentially operable patients with no signs of mediastinal involvement on CT or PET may benefit from presurgical staging with EBUS-TBNA.4 EBUS-TBNA is a less invasive way to reliably sample mediastinal lymph nodes in patients who may have respiratory insuffi ciency from emphysema or radiation fi brosis or who are too weak from previous chemotherapy to tolerate an invasive surgical procedure. EBUS-TBNA may also assist during follow-up of NSCLC patients with concurrent lymphadenopathy from sarcoidosis or granulomatous diseases, another diagnostic dilemma frequently faced by the oncologists.  EBUS-TBNA is becoming a valuable tool in the algorithm of lung cancer detection. It is safe, reliable, and cost-effective, with minimal complications.

Dr. Islam is an assistant professor and director of interventional pulmonary medicine in the Division of Pulmonary, Allergy, Critical Care and Sleep Medicine at the Ohio State University Medical Center.

Lately, ultrasound has been used to increase sampling accuracy. Trans-thoracic ultrasound does not provide adequate guidance because of the difficulty in imaging the mediastinum

Endobronchial Ultrasound: An effective tool in the diagnosis of mediastinal lymphadenopathy and lung cancer

I entered into the blogosphere a bit late, I know. I straddle a bit of a generation gap; I am too old to be a part of the younger generation that sees no trouble with sharing nearly everything online (yes, that means I don’t do Facebook or other social networking sites), but I am online more than my colleagues (because I do use LinkedIn, the professional networking site, for example). I started reading blogs in earnest when I was on maternity leave with my fi rst child (idle hands do become the devil’s playground). Mostly, I focused on “mommy blogs” and personal (not group) blogs. Eventually, I made my way over to celebrity and gossip blogs, fashion blogs, and cooking blogs—basically hobbies or outside interests (who knew the devil’s playground could be so broad and varied?).

It wasn’t for several years until I started really reading professional development and then medical blogs. And somewhat to my surprise, I found them quite useful professionally—they offered me good tips for my career, and quick summaries of important, recently released articles. Also, I fi nd that lay press articles about cancer are often cited in blogs, and I can at least have some knowledge of the things my patients bring to me in the clinic by that mechanism. Through all of this, I realized that most people who read blogs have a blog of their own (at least it seemed that way to me).

Still, I had no interest in starting my own blog at that time. I wasn’t sure I had a voice, or even if I did, that anyone would want to listen.  And I had some concerns about how blogging would aff ect my work life. I knew from making some early online errors that patients have a way of turning up everything you have ever done with your real name via Google and an hour to kill. This is the curse of having an unusual name, and a need to post comments using your real name, I suppose. I wasn’t sure that I would want all of my patients able to read (in essence) my online journal. This says nothing about the intensely personal nature of what I do with patients—the conversations about dying, about chemotherapy, about advanced directives. With so much of what I do covered under HIPAA, what would I have to blog about anyway?

As it turns out, I do have a voice, and I have a lot to say. The way that I started blogging was all quite serendipitous; a physician friend was approached to start a blog as part of an online companion to a print magazine, and I just tagged along. When I saw him doing it, I thought, “Shoot, I can do that.” I come at my blog with an unusual perspective in that I am a geriatric oncologist. I also practice at an academic center and specialize in gastrointestinal oncology. I think that all of these perspectives inform what I consider to be “blog-worthy.” Th e cancer blog world also suff ers from an abundance of young females with breast cancer, and I lend a diff erent perspective to that arena. Most cancer blogs are also written from the patient perspective, and I bring the provider voice to the story. I have mostly a professional blog, and frequently I wish my blog had more of a personal feel to it, but in medicine, I don’t think you can do that with your job title right on the byline. Many of the best blogs are anonymous, and I think that anonymity allows the author to speak absolutely freely.

I’m not sure how others approach their blog, but my process is pretty simple. I am on several list-serves for cancer news organizations and professional groups (like the American Society for Clinical Oncology), which produce daily or weekly e-mails. I scan those regularly and read in depth what seems most interesting to me. I also summarize meetings that I attend, particularly focusing on practice-changing study results. I review the 

, MSNBC, and CNN health pages for cancerrelated articles. I pay attention to issues in my clinical practice that elicit some controversy or disagreement among my colleagues. And like most bloggers, I go through others’ blog rolls for possibly interesting sites. I produce an average of two blog entries per week, and with my other job responsibilities, this seems about the maximum I can realistically produce.  I really like that I can blog once my kids are in bed, on my own time.

Although I like the process of blogging, I certainly don’t love everything I have ever blogged about. A lot of what I have written about seems a little boring to me now, and some of it seems too superficial. What makes blogs great—the usual short length&mdash;can also take away from the complexity of medical literature interpretation. Can you really summarize a phase III randomized trial with important correlative studies in only 300 words? I feel foolish when things I have emphasized end up not being true in larger studies. I feel most foolish when I pour my heart into a posting only to have no one leave a comment, good or bad, about it. But bloggers need to develop a thick skin when putting their opinions out there for all to read. I know that many more are reading than are commenting. Whenever you blog about one particular type of cancer, you always run the risk of other “competing” cancer advocates arguing with you about why their cancer is most important. Usually, I just delete those e-mails, because really, aren’t all cancers important?

Most of my patients like my blog—they do read it, and they click on the links. One of the things about geriatrics is that you are frequently “treating” the family in addition to the patient, and thus I have received nice feedback from concerned children and spouses, as well. I know some of the people I work with have read my blog entries, which has spawned new collaborations for research. It seems funny to me that I can work right down the hall from someone and not realize that they have the same research questions that I do. I think it heads off some of the common questions so that I can focus my consultation with them a bit. I also think it informs potential patients about my usual practice patterns, so they can more carefully choose whether they would like to see me for their cancer care.

I’m not sure how long I will keep on blogging; I am shooting for a year or two. But certainly, oncology is evolving at a quick-enough pace that I should have material to carry on beyond that if I want to. “One day at a time,” I say. If cancer has taught me one thing, that is it.

Dr. LoConte is the author of an ongoing blog for 

and an assistant professor of medicine at the University of Wisconsin Comprehensive Cancer Center and the School of Medicine and Public Health in Madison, WI.

It was not for several years until I started really reading professional development and then medical blogs. And somewhat to my surprise, I found them quite useful professionally.

The Ins and Outs of Oncology Blogging

	Contemporary treatment of primary cancer may involve surgical resection, single- or multiple-agent chemotherapy, radiation, hormonal, or targeted biologic therapy. Secondary management may include treatment of or assistance with nausea/emesis, pain, anemia, depression, disability, impaired communication, and other issues. The complexity of this process means that it will be filled with transitions. Patients will receive care from multiple providers, in multiple locations. Active treatment will give way to follow-up care, which in turn will yield to extended “survivorship” management. If improperly handled, each of these hand-offs can be problematic, confusing or worrying the patient and compromising the ability of providers to deliver optimal care.  Managing these transitions can be diffi cult, requiring as it does that an enormous amount of information about each patient and his or her disease be shared quickly and accurately among many providers.  If only there were a tool, let’s say a vast network of computers on which this data could be stored and accessed from multiple points of entry, to ease the process...

	There are hundreds of definitions of “continuity of care,” but we like the one proposed by 

, et al. best: “for patients and families the experience of continuity is the perception that providers know what has happened before, that different providers agree on a management plan, and that a provider who knows them will care for them in the future.” Haggerty and colleagues suggested three types of continuity; in the same year, 

, MD, introduced two more (see Table).  The experience of a patient with cancer may be divided into two phases: the period of time during which active treatment is provided, and the “survivorship” period, during which therapy has been completed and/or cancer is controlled, but follow-up care continues. Th ese phases are not always distinct, may overlap, and may even alternate. Eff orts at ensuring any of the types of continuity described above must take into account both phases.

	Continuity of care is important during active treatment. A cancer diagnosis is confusing and frightening, and the treatments administered may produce adverse reactions that exacerbate symptoms related to progression of disease. Lack of continuity may make patients feel insecure—“my doctors can’t agree on how to help me; maybe none of them know what they’re doing”&mdash;and less likely to adhere to their treatment plans. It also introduces any number of other potential problems.  To understand how, consider the standard treatment workfl ow for a patient with cancer.  A patient will arrive on the day of treatment and undergo testing and physical examination.  During this time, the oncologist will conduct an assessment of any adverse events encountered since the last session. Th e oncologist will then issue an order for the treatment agent(s). The patient will then move to a treatment room, where a nurse administers therapy prepared by a pharmacist and documents treatment to be reviewed by the oncologist at a later date.  Th e patient is discharged. Before the next session, the patient may visit his or her primary care physician (PCP) and/or the hospital for emergent complaints.

	Now, consider the opportunities for error inherent in this system, if information and management planning do not combine to make a continuous care experience. The oncologist may make prescribing errors or be unaware of drug—drug interactions (especially if the patient was prescribed a new drug by his/her PCP and forgets to inform the oncologist).  Chemotherapy-related toxicity that occurs and is managed between treatment sessions may not be reported to the oncologist. The nurse administering therapy may not have access to important patient-specifi c notes that aff ect the administration.

	These issues come into even more stark relief during times of emergency. Hurricane Katrina displaced thousands of people, many of whom were cancer patients receiving active treatment.  Some patients presented to hospitals with only the most basic information about their cancer—“I get chemo for breast cancer, but I don’t remember the name. Stage? I can’t remember.”&mdash;and limited information on allergies, treatment history, and the like.

	According to the Institute of Medicine (IOM) report Lost in Transition: From Cancer Patient to Cancer Survivor, more than 10 million Americans have a history of cancer (and are therefore defined as “cancer survivors”). Issues associated with continuity of care deepen considerably during the post-treatment period. During active treatment, the regimented nature of the treatment workflow prevents the most egregious continuity problems. In 1985, physician and cancer survivor 

 defined three “seasons of survival.” The first “season,” the acute phase, begins with diagnosis and involves dealing with treatment. During this period, said Mullan, “simply coping with the effects of the therapies occupies all the adaptive energies of most patients.” After the fi rst course of therapy, or remission, patients will enter what Mullan termed the extended and eventually permanent seasons of survival. During this period, patients will deal with follow-up and maintenance therapy.

	They may want to go back to work; have to deal with limited mobility, communication, or cognition; return to regular visits with their PCP; or experience feelings of depression and anxiety for which they seek help. The degree of difficulty involved in maintaining continuity of care is considerable. This is especially true given that most oncologists have little formal training in survivor care. Moreover, PCPs—and other providers&mdash;may not be conversant with the intricate details of a patient’s cancer and have little ability to communicate directly with the oncologist. Finally, there is no definitive “best practice” for the care of cancer survivors, meaning that continuity will necessarily suffer as different practitioners operate according to their own preferences.

	The IOM defines four essential components of survivor care:

		Surveillance against metastasis, recurrence, or adverse effects of disease and treatment

		Intervention for any adverse effects, including physical symptoms, psychological distress, and for problems with insurance and employment

		Coordination among all providers, including mental health professionals, PCPs, oncologists, and support staff

	Overcoming the obstacles described so far to achieve eff ective continuity in the survivorship period will require a new paradigm.  What we will do and what we have done Of the types of continuity described in the table, informational continuity feeds most of the others. With access to the right information, diff erent providers can provide logical care specifi c to the needs of the patient (management continuity) and his or her family (familial continuity), regardless of location (geographic continuity). At heart, informational continuity is a simple record, which defi nes what we will do and what we have done.

 recommend the creation of treatment and survivorship plans, developed in advance with feedback from the patient. A treatment plan would summarize all elements of treatment to be administered, including information on cancer stage and type. A survivorship plan would address timing of recommended followup, recommendations for healthy lifestyle and prevention of recurrence, information on employment and insurance issues, and information on the availability of psychosocial services as needed. Plans of this type would encourage patient involvement in the treatment process and prompt the patient to ask any questions at a time when the questions and answers could be documented and examined by future providers, thus ensuring that answers are consistent, or at least that changed answers can be clearly explained.

	On the other end of the process, a treatment summary describing treatments administered, any adverse events, allergies, patient preferences, and follow-up and maintenance care, would allow future providers to obtain a comprehensive picture of everything a given patient has experienced. The 

National Coalition for Cancer Survivorship

 conducted a workshop in which patients, oncologists, and PCPs were shown a treatment summary like the one described above. Patients considered the summary valuable; PCPs agreed, to the point that they would preferentially refer patients to an oncologist who provided such a summary.  Oncologists were, understandably, worried about the time investment required to generate a summary.

	All the same, the momentum behind a push to generate treatment plans and summaries for every oncology patient is growing. The 

Comprehensive Cancer Care Improvement Act

, currently under consideration as HR. 1078 and in the Senate as S. 2790, is designed to support care that combines treatment with symptom management. Key among the provisions of this bill would be the proposal that cancer survivors completing treatment be given a thorough treatment summary and follow-up plan; the bill would authorize Medicare reimbursement for oncologists for the preparation of such a plan.

	The easiest and most eff ective way to generate a truly comprehensive treatment summary is through an EHR that automatically generates the summary in real time as new information is added to the record. At an ASCO roundtable convened January 23—24 in Washington, DC, thought leaders representing practicing oncologists, EHR vendors, advocates, and others described the key elements of an ideal oncology EHR, deciding that it should include the ability to store:

		A detailed treatment plan, including information on diagnosis, performance status, goals of therapy, and expected toxicities

		Dynamic generation of a treatment summary, including information on dose reductions, reason for discontinuation, and treatment-emergent adverse events

		The ability to create a chemotherapy workflow sheet

		Alerts for drug interactions and dosing safety

American Society for Testing and Materials

 has developed a core set of data that would be sent to each provider to whom a patient is referred. This standard (called the Continuity of Care Record) includes a treatment summary developed according to the guidelines outlined above, to be easily generated via an EHR. For more on the Continuity of Care Record, including a list of EHR vendors working toward compatibility with this standard, visit the 

American Academy of Family Practice’s Center for Health IT

	Of course, as with most matters related to EHRs, there are challenges. Funding to support widespread incorporation will have to be obtained; provider workflow will need to be re-engineered to allow for more comprehensive entry of data into an EHR. By far the most signifi cant issue, however, is the subject of interoperability. At present, there are hundreds of EHR vendors; the ability of these disparate products to communicate with one another is variable. According to Center for Health IT Senior Advisor David C. Kibbe, MD, without the ability to share data, “each doctor’s offi ce or clinic is simply an island of data without the means of accessing or exchanging the stored patient information it contains.” Interoperable systems in this context are systems that can electronically exchange treatment summary information among different caregivers (potentially using disparate EHRs or practice management systems).

	Interoperability is a significant enough subject to warrant an article of its own, but very broadly speaking eff orts at interoperability are directed toward two goals:

		“Plug-and-Play” — function eff ectively along with other systems even if those other systems are created by different manufacturers.

		Extensibility — technology that can potentially be used in a variety of ways. 

	Solving these problems may take a large investment of time and money, but could ultimately save nearly $80 billion a year, according to HIMSS.

Frank Ferrara is a freelance healthcare journalist and a former

Continuity of care is important during active treatment. A cancer diagnosis is confusing and frightening, and the treatments administered may produce adverse reactions.

Healthy Transitions: Information technology can and should play a key role in improving continuity of care for patients with cancer

Convenient, remote information access; interconnectivity; and a host of other key features has led the healthcare industry to embrace the Internet, as evidenced by the proliferation and success of for-profit sites like 

Neuroleptic Malignant Syndrome Information Service

However, the Internet has evolved beyond its origins as a collection of interconnected websites with static information. It has become a medium through which relationships are established, information is shared and aggregated, and communities are developed. 

, a virtual online world, has become a popular destination not just for recreation, but business as well. Blog authors now have a large readership base on par with some newspaper columnists. User-generated content is fast becoming the dominant online business model. The healthcare industry has embraced this trend, utilizing the Internet to do everything from publishing electronic versions of clinical journals to conducting business online with Web-based forms for prior authorization of medications and enabling patients to fi nd the right healthcare provider in an insurance network. This trend has been referred to as 

, and many new healthcare companies have adopted this paradigm, calling it Health 2.0.

, an advocate for free and open source software and the author of many “gold standard” technical manuals, is widely acknowledged as the originator of the Web 2.0 concept. Th ere are several signifi cant principles of Web 2.0, the first being the idea of the “Web as a platform.” An analogy is that 

 is a document platform company but not a publisher of electronic texts.

Another important principle of Web 2.0 is that “the service automatically gets better the more people use it.” This is how the additive eff ect of more computers increases not only the number of websites, but actually provides a service. For example, the 

 project of Stanford University harnesses the idle computing power of computers and powerful gaming systems such as the PlayStation 3 on the Internet to study protein folding and misfolding via a distributed computing system. Participants can check on how much they have contributed and see how they rank against other contributors. In the spirit of competition, the hardware site 

 is hosting a competition to see which group reaches 5 million points first.

In a similar vein, another principle of Web 2.0 is that the Internet as a medium has created the opportunity to harness the collective intelligence of the entire online community. 

 is a prime example of this concept. The name comes from “Wiki,” a Hawaiian word for “quick,” and “pedia,” as in encyclopedia. In Web terms, a wiki is a collection of pages designed to enable anyone to contribute or modify content. Users can add pictures, video, and create links to information on other sites in addition to adding explanations, definitions, and other content. Wikipedia is a popular destination because it provides information on an unbelievably wide range of topics. Sharing resources online in large virtual communities is another key feature of Web 2.0, as exemplified by sites such as 

. At Del.icio.us, after users create an account, they can bookmark favorite sites and “tag” them with keywords, enabling other users on Del.icio.us to search for and discover these sites.

Del.icio.us keeps track of how many other people save these sites as well, which provides another measure of which websites and content the community deems most relevant. In addition, Del.icio.us users can join up with one another to create networks and alert others in their network of new sites. Digg takes a similar approach, in that users tag and submit interesting and useful sites for appraisal and comment by other Digg members, who rate them either as digg (positive) or bury (negative). Digg users can search based on most popular story, least popular story, newest story, oldest story, and most-commented-on story.

 is a healthcare-based sharing tool that works in the same way as Del.icio.us and Digg but it is restricted to physicians, nurse practitioners, and physician assistants only. RSS, or “really simple syndication,” is another popular method of sharing content.  Easy to download and use, RSS readers enable users to subscribe to “feeds” that deliver news and other information from their favorite websites and other information sources. In essence, RSS feeds enable the user to have multiple sources of information pulled into the reader program, which also tracks which content is new and which has been read. For example, 

 offers the option of sending search results as an RSS feed, so that any new journal that meets the user-generated search terms will appear in that person’s RSS reader.

Depends on who you ask. A variety of healthcare thinkers and pundits have off ered competing defi nitions of Health 2.0.  Matthew Holt, founder of the 

, sees Health 2.0 as a user-generated phenomenon. Scott Shreeve of 

 says that Health 2.0 companies provide the venue to transform healthcare, whereas Jos Bakker of Philips Medical Systems sees Health 2.0 as the next evolution in the Web space for the 

. Perhaps the best way to understand the Health 2.0 trend is to review some of its leading companies.

One of the new trends in Health 2.0 is improved healthcare information searching.  Health-specific search engines, such as 

, improve on existing search engines like 

 by searching not only the Internet, but specific sites, including ClinicalTrials.gov and PubMed, with specific health-related terms from medical taxonomies. These taxonomies likely include Medline’s 

Systematized Nomenclature of Medicine-Clinical Terms

 (NCI) Thesarus.  These search engines also search specific sites that have earned 

Utilization Review Accreditation Commission

 (URAC) certification. The health search engines employ specific algorithms to implement the medical taxonomies, as well as utilize health experts, to refine the search terms (especially consumer-focused terms). 

 takes a slightly different approach. Instead of relying on algorithms and semantic analysis, it adds the wisdom of trained expert search guides and physician reviewers.

 are among the most wellknown social networking sites on the Internet.  Many patients have gravitated to these sites to create a presence on the Internet for themselves, as well as to establish links to their friends and business colleagues. In the Health 2.0 world, social networking among patients has taken on new meaning.  At 

, patients can create an online journal, join an online support community, and invite family and friends to join. Activities are communicated via e-mail alerts to community news and friends. Members give virtual “hugs” to help support one another, providing support almost 24/7. At 

, the social context takes the sharing of patient experiences further; although it focuses right now on Parkinson’s disease, multiple sclerosis, HIV/AIDS, and amyotropic lateral sclerosis, patients on the site not only share their symptoms, but also data on their treatment, which are tracked. Th is information is then plotted graphically over time, which helps others see the outcome of treatment on specifi c symptoms. 

also provides support communities for patients but adds topic-based forums featuring physician experts.

 is the largest professional network online, with more than 20 million members. It offers a variety of services, including job postings, the ability to post questions to one’s network or the larger community, and discussion forums. One of the key features is the ability to see network updates, such as the new connections of your primary connections, as well as any changes to their profi les. The site is extremely popular with recruiters, who typically have over 500+ connections. But the medical community represents less than 4% of total users.  In the Health 2.0 space, 

 is the largest online healthcare community, with more than 60,000 members.

At this site, physicians pose questions and answers so that clinical findings and unusual events can be shared, with the collective knowledge advancing patient care in a peer-review manner. Physicians are verified when they join but can maintain a relatively anonymous profile. Pharmaceutical companies and other groups can pay to access the observations and clinical insights posted on Sermo. 

 also pools and shares clinical pearls similar to Sermo, but its revenue comes from medical technology companies that sponsor forums seeking user experiences.

 also allows members to share clinical pearls but adds sections for business practice and personal interests. 

 has a more professional focus compared to the sites above. Its goal is simply networking, and not collective information aggregation. Within3 has both research and clinical communities, as well as individual and institutional members, national and international members, and groups with the idea of facilitating information exchange, whether it’s a clinical trial or referral for care.

Although the definition of Health 2.0 may be a moving target, the essence is that the “Internet as a platform” concept creates opportunities for both patients and providers—the whole is greater than the sum of its parts. It has become a dynamic entity, with many similar sites that are also diff erent in subtle ways. Which sites will prevail and dominate is too difficult to predict in the post-dot-com era, but certainly the time to try is now, instead of waiting.

Dr. Luo is the Physician Editor-in-Chief of

, and chief of consultation and liaison psychiatry in the department of psychiatry at the UCLA Semel Institute for Neuroscience and Human Behavior.

The Internet has evolved beyond its origins as a collection of interconnected websites with static information. 

Taking the Wheel: The People and Companies Driving Health 2.0

Matthew Holt is a ubiquitous presence in the online world of Health 2.0. He is the proprietor of 

, essential reading that promises to tell you “everything you always wanted to know about the health care system. But were afraid to ask;” he is an in-demand healthcare strategist, consultant, and 

; and he is one of the organizers of the Health 2.0 — User-generated 

. We spoke with him about the ideas underlying Health 2.0 and where he sees this movement continuing.

	My simple definition is that Health 2.0 is the use of Web 2.0 technologies in healthcare. Typically, Web 2.0 technologies include blogs, wikis, discussion and community sites, and those that make it very easy for technology users, rather than publishers, to generate content and share it with each other.

2 How are Health 2.0 applications currently being used in healthcare?

	There’s a fantastic patient community called 

, where patients keep a kind of diary that’s like an electronic medical record for themselves, including detailed information about what is going on in their lives and all they are doing to cope with their diseases. A huge amount of information gets shared. Th ere have been online communities in diff erent formats since the early ‘90s, and now Health 2.0 off ers tools and technologies that make it easier to use them. By using forums like PatientsLikeMe and with the increased ability to search these forums, people can fi nd useful information more easily. Usually, a doctor sees a patient, sees what their symptoms are, and usually has one to three diagnoses in their mind at the time. But many times, there is a wrong diagnosis or incomplete diagnosis, or there is a rare disease that is showing up like a more common disease.  Th e impact of the ability to search into other people’s experiences and match with cases online in these communities is going to be substantial. A doctor may see one or two of these cases in a lifetime, but there may be 20 or 30 or 1,000 of these people, and if you can put them all together in one group, it makes the information much easier to find.

3 How long will the Health 2.0 movement continue?

	I would argue that the incorporation of these applications into all kinds of business and activity online is going to keep going, because it’s another wave of technology. People are not going to stop caring about their patient community or their disease.  Companies are going to fi gure out what tools and technologies people are fi nding useful and adapt their business processes accordingly. In healthcare, there’s also non-commercial interest, so things will be supported by foundations and patient groups, with or without the actual success of individual Health 2.0-type companies. Even if Revolution Health or PatientsLikeMe goes away, I think these tools will continue to be used, both by healthcare organizations as part of their Web eff orts, and by nonprofit groups and patient communities.

4 What are your views on Revolution Health?

	I like RevolutionHealth.com as a website. I think they’re trying to do basically everything across the board in terms of Health 2.0, putting together all these diff erent tools for consumers to use to interact with each other around their health. I think they’ve done quite a nice job. But the problem with Revolution Health is if you call yourself “Revolution” and you start off by making a huge splash, you’re going to be disappointed whatever you do. So, I think if you ignore what Steve Case said when he started it and ignore the name, it’s a nice website. It’s building traffic—mostly by acquisition&mdash;and they’ve now got a lot of good pieces in place and some traction in terms of the market place. The problem from a business perspective is, if you start off spending a huge amount of money the way they did, and take on huge numbers of people, it’s very hard to understand how they are going to make a huge amount of money doing it. But time will tell on that one. It took 

 a long time to fi gure out their business, but they are doing well these days.

5 Do you see a lot of misconceptions regarding Health 2.0?

	I think any time you’re talking about something as complicated and with as many vested interests as the healthcare system, saying that we’re going to change the healthcare system using Health 2.0 is over-ambitious. Some people are at the risk of grafting other things like the concept of transparency of data too.  Health 2.0 is going to help with that, but it’s not going to completely force that on the market. I think if you say Health 2.0 is going to change healthcare as we know it in every aspect and immediately, you’re going to be disappointed. But if you say we expect to see Health 2.0 adopted by more and more patients, physicians, and healthcare organizations, I’d agree; I’m sure it could slowly change the way healthcare is delivered and the way people manage their health.

Matthew Holt is a ubiquitous presence in the online world of Health 2.0. He is the proprietor of The Health Care Blog, essential reading that promises to tell you Ã¢ï¿½ï¿½everything you always wanted to know about the health care system.